Information Collection

FIMR/HIV Maternal Interview Form

IC 198412 under ICR 201107-0920-001 · OMB 0920-0902.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 FIMR/HIV Maternal Interview Form	Form and Instruction
2 Maternal Interview Consent Form Maternal Interview Consent Form.docx	Form and Instruction
1 Maternal Interview Form Maternal Interview Form.docx	Form and Instruction
Attachment 3.c Maternal Interview Form - Creole.pdf Attachment 3	IC Document
Attachment 3.d Maternal Interview Form - Spanish.pdf Attachment 3	IC Document
Attachment 3.b Maternal Interview Form - French.pdf Attachment 3	IC Document
Attachment 4.d Maternal Interview Consent Form - Spanish.doc Attachment 4	IC Document
Attachment 4.c Maternal Interview Consent Form - Creole.doc Attachment 4	IC Document
Attachment 4.b Maternal Interview Consent Form - French.doc Attachment 4	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Maternal Interview Consent Form	Maternal Interview Consent Form.docx		Yes	No	Fillable Fileable
Form and Instruction	1	Maternal Interview Form	Maternal Interview Form.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 3	Attachment 3.c Maternal Interview Form - Creole.pdf	07/01/2011
Attachment 3	Attachment 3.d Maternal Interview Form - Spanish.pdf	07/01/2011
Attachment 3	Attachment 3.b Maternal Interview Form - French.pdf	07/01/2011
Attachment 4	Attachment 4.d Maternal Interview Consent Form - Spanish.doc	07/01/2011
Attachment 4	Attachment 4.c Maternal Interview Consent Form - Creole.doc	07/01/2011
Attachment 4	Attachment 4.b Maternal Interview Consent Form - French.doc	07/01/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.